COSMETIC Outcomes Article
Patient-Reported Outcomes in Weight Loss and Body Contouring Surgery: A Cross-Sectional Analysis Using the BODY-Q Lotte Poulsen, M.D. Anne Klassen, D.Phil., Ph.D. Michael Rose, M.D. Kirsten K. Roessler, D.Phil., Ph.D. Claus Bogh Juhl, M.D., Ph.D. René Klinkby Støving, M.D., Ph.D. Jens Ahm Sørensen, M.D., Ph.D. Odense and Esbjerg, Denmark; and Hamilton, Ontario, Canada
Background: Health-related quality of life and satisfaction with appearance are important outcomes in bariatric and body contouring surgery. To investigate these outcomes, scientifically sound and clinically meaningful patient-reported outcome instruments are needed. The authors measured health-related quality of life and appearance in a cohort of Danish patients at different phases in the weight loss journey: before bariatric surgery, after bariatric surgery, before body contouring surgery, and after body contouring surgery. Methods: From June of 2015 to June of 2016, a cross-sectional sample of 493 bariatric and body contouring patients were recruited from four different hospital departments. Patients were asked to fill out the BODY-Q, a new patientreported outcomes instrument designed specifically to measure health-related quality of life and appearance over the entire patient journey, from obesity to the post–body contouring surgery period. Data were collected using REDCap, and analyzed using SPSS software. Results: For all appearance and health-related quality-of-life scales, the mean score was significantly lower in the pre–bariatric surgery group compared with the post–body contouring group. Furthermore, the correlation between body mass index and mean scores was significant for all appearance and healthrelated quality-of-life scales, with higher scores associated with lower body mass index. The mean score for the group reporting no excess skin compared with the group reporting a lot of excess skin was significantly higher for five of seven appearance scales and four of five health-related quality-of-life scales. Conclusion: This study provides evidence to suggest that body contouring plays an important role in the weight loss patient’s journey and that patients need access to treatments. (Plast. Reconstr. Surg. 140: 491, 2017.)
O
besity has more than doubled since 1980,1 and a meta-analysis on body mass index and mortality showed that mortality in people with a body mass index over 25 kg/m2 increased approximately log-linearly.2 Bariatric surgery has been shown to be the most effective treatment of moderate to severe obesity, which From the Department of Plastic Surgery, the Odense Patient Data Explorative Network, the Center for Eating Disorders and Department of Endocrinology, and the Department of Plastic Surgery, Odense University Hospital; the Department of Pediatrics, McMaster University; the Departments of Plastic Surgery and Endocrinology, Hospital of Southwest Jutland; and the Institute of Psychology and the Psychiatric Services in Southern Denmark, University of Southern Denmark. Received for publication December 23, 2016; accepted March 21, 2017. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003605
has led to an increasing number of bariatric procedures performed worldwide.3–5 Health-related quality of life is important to patients seeking bariatric surgery,6 and weight loss following bariatric surgery is associated with improvement in health-related quality of life.7,8 However, massive Disclosure: The authors have no financial interest to declare in relation to the content of this article.
Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www. PRSJournal.com).
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Plastic and Reconstructive Surgery • September 2017 weight loss often leads to excessive skin, which has the potential to have a negative influence on health-related quality of life. Therefore, body contouring surgery is often needed to restore body image and further improve health-related quality of life.9 To measure outcomes such as health-related quality of life and satisfaction with appearance, patient-reported outcome instruments are needed. As described elsewhere,10,11 there is a need for a well-developed patient-reported outcome instrument that can be used across the weight loss journey for bariatric and body contouring patients.12–16 In a recent review, Gilmartin et al. suggest that the newly published BODY-Q could be a candidate tool.17 The BODY-Q is a new patient-reported outcome instrument designed specifically to measure patient-reported outcome over the entire patient journey, from obesity to the post–body contouring surgery period.18,19 The BODY-Q was developed following internationally recommended guidelines for patientreported outcome instrument development.20–25 A strength of the BODY-Q is the use of Rasch measurement theory, which provides interval level measurement scales.21,26 The BODY-Q measures three overall domains—appearance, health-related quality of life, and the patients’ experience of health care—in terms of 18 independently functioning scales. In addition, the BODY-Q includes an obesity-specific physical symptom checklist. In Denmark, the BODY-Q was translated into Danish in a linguistic validation study.10 In addition, a psychometric validation study was performed with the findings described in detail elsewhere.10,11 Briefly, the Danish version of the BODY-Q was found to be acceptable to Danish patients (e.g., high response rate and low amount of missing data) and to evidence reliability (Cronbach alphas > 0.90 and person separation indices > 0.80 for the appearance and health-related quality-of-life scales).11 The objective of this study was to measure health-related quality of life and appearance using BODY-Q scales in a cohort of Danish patients at different phases in the weight loss journey. Our specific aim was to explore relationships between BODY-Q scale scores and the following variables: (1) phase of weight loss journey (i.e., before bariatric surgery, after bariatric surgery, before body contouring surgery, and after body contouring surgery); (2) body mass index; and (3) amount of self-reported excess skin.
PATIENTS AND METHODS Before commencement, the study was reported to the Danish Data Protection Agency and the Regional Scientific Ethical Committee of Southern Denmark. As our study consists of a questionnaire survey, the ethical committee did not find reason for an approval. Data Collection and Sample The study was carried out as an online questionnaire survey using the Danish version of the BODY-Q.10,11 Patients from the region of southern Denmark were recruited from four different departments: the Department of Endocrinology, Hospital of Southwest Jutland; the Department of Endocrinology, Odense University Hospital; the Department of Plastic Surgery, Hospital of Southwest Jutland; and the Department of Plastic Surgery, Odense University Hospital. All patients seen at the following time points between June of 2015 and June of 2016 were invited to complete the BODY-Q: (1) first visit at the weight loss clinic; (2) before the bariatric surgery appointment; (3) 4 to 5 months after bariatric surgery; (4) 12 months after bariatric surgery; (5) 24 months after bariatric surgery, (6) before body contouring surgery; (7) 3 months after body contouring surgery; and (8) 12 months after body contouring surgery. Data were collected using a REDCap (i.e., Research Electronic Data Capture) database designed for this study (http://project-redcap. org). Access to REDCap was granted through the Odense Patient Data Explorative Network.27 Patients received a letter together with their appointment information and information about the study with a link to access the electronic REDCap link to complete the BODY-Q. At the Hospital of Southwest Jutland, patients received mobile text reminders before their scheduled appointment. The text messages included a reminder to fill out the BODY-Q before their outpatient visit. Through the last 3 months of the study, we aimed to invite patients who failed to complete the questionnaire in advance of their appointment to do so on arrival to the clinic using a tablet. Outcome and Demographic and Clinical Variables The online survey included the BODY-Q appearance scales (body, abdomen, upper arms, buttocks, back, inner thighs, hips/outer thighs, skin, and body contouring scars) and health-related quality-of-life scales (body image and physical, psychological, sexual, and social function), plus relevant demographic
492 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 140, Number 3 • Patient-Reported Outcome and Weight Loss and clinical questions. The sample was categorized into four subgroups as follows: (1) pre–bariatric surgery (i.e., participants recruited at their first visit to the weight loss clinic or at the pre–bariatric surgery appointment); (2) post-bariatric surgery (i.e., participants recruited at the 4- to 5-month or 12-month follow-up appointments); (3) pre–body contouring (i.e., participants recruited from any of the body contouring clinics who reported that they had never previously undergone any body contouring surgery, but needed surgery to remove excess skin from any part of their body); and (4) post–body contouring (i.e., patients recruited from any of the body contouring clinics who had previously undergone at least one body contouring procedure to remove excess skin). For body contouring participants, we also computed a set of dichotomous variables to compare BODY-Q scores for participants who reported being either preoperative or postoperative for body contouring to remove excess skin from the following areas of their body: abdomen, arms, back, buttocks, inner thighs, and hips/outer thighs. Finally, to explore relationships between amount of excess skin and BODY-Q scores, patients were asked to self-report the amount of excess skin they have on their body as follows: none, a little, a moderate amount, or a lot. Statistical Analysis BODY-Q scales can be scored if at least half of the items are completed (the mean is imputed when there are missing data). For each scale, the raw score was computed and converted to a Rasch transformed score (range, 0 to 100). Low BODY-Q scores indicate low satisfaction with outcome, whereas higher scores indicate a better outcome. To test equality of the mean, we computed either a parametric (t test or one-way analysis of variance with Tukey post hoc test) or nonparametric (Mann-Whitney U tests or Wilcoxon) test, depending on the distribution of the data, after examining homogeneity of variance and normality assumptions. A value of p < 0.05 was considered statistically significant, and 95 percent confidence intervals were computed. Data analysis was performed using IBM SPSS Version 22 (IBM Corp., Armonk, N.Y.).
RESULTS Sample Characteristics A total of 493 patients completed the BODY-Q. Sample characteristics are shown in Table 1. For the bariatric group, the response rate was 83 percent; for the body contouring group, the response rate
was 72 percent. The overall response rate was 76 percent. Details on the distribution of weight loss method and type of bariatric surgery are provided in Table 2. As patients were recruited over a 1-year period, some patients (13 percent) were asked to complete the BODY-Q more than once (Table 3). The 493 patients provided 559 assessments, 19 percent by pre–bariatric surgery patients, 20 percent by post–bariatric surgery patients, 28 percent by pre–body contouring surgery patients, and 33 percent by post–body contouring surgery patients. For the 339 patients in the body contouring group, 155 were preoperative and had never had any surgery. The remaining 184 patients in this group were post–body contouring surgery patients for at least one of the seven areas of the body, of which 107 respondents had undergone surgery on more than one part of the body. Within the post–body contouring group, 88 patients reported to be at the 3-month follow-up at the time of assessment. The most common procedure was correction of the abdomen, which 92 percent of the post–body contouring group had undergone. Details on the number of patients to report having undergone surgery for the seven different areas of the body, and the cumulative number of procedures reported, are listed in Table 4. Table 5 shows the number of reported areas in the subanalysis of before and after body contouring surgery according to different parts of the body. For an overview of the mean scores and analysis of variance findings by phase of weight loss journey for each BODY-Q scale, see Appendix 1. (See Appendix, Supplemental Digital Content 1, which shows the mean scores and associated statistics for BODY-Q scales by phase of weight loss journey, http://links.lww.com/PRS/C330.) Appearance Scales Analysis by Phase of Journey Figure 1 illustrates the BODY-Q appearance scales by phase in the weight loss journey. For the seven appearance scales, the mean score was significantly lower in the pre–bariatric surgery group compared with the post–body contouring group (p < 0.001). For six of seven areas (exception: arms) scores were significantly lower in the pre–bariatric surgery group compared with the post–bariatric surgery group (p ≤ 0.011), and the post–bariatric surgery and pre–body contouring groups differed significantly (p < 0.001) on two of seven scales (body and abdomen), with the pre–body contouring group reporting lower scores. Pre–body contouring patients reported significantly lower scores (p ≤ 0.027) on four of seven scales (body, abdomen, back, and buttocks)
493 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • September 2017 Table 1. Sample Characteristics, Divided by Phase of Weight Loss Journey* Characteristic No. Age, yr Mean Range Sex Female Male BMI Normal (18.5–24.9 kg/m2) Overweight (25–29.9 kg/m2) Class I (35–39.9 kg/m2) Class II (35–39.9 kg/m2) Class III (≥40 kg/m2) Self-reported amount of excess skin None A little Moderate A lot Comorbidity Yes No Marital status Married Living together Widow Separated Divorced Single, never married Education None Primary school Youth, vocational, or secondary education Short higher education Medium higher education Long higher education Ph.D. or master’s
No.
559 548
464
553 552
557
Before Bariatric Surgery (%)
After Bariatric Surgery (%)
Before Body Contouring (%)
After Body Contouring (%)
107
113
115
184
43 21–63
42 23–65
42 17–66
44 23–75
72 (67) 35 (33)
82 (73) 31 (27)
123 (79) 32 (21)
160 (87) 24 (13)
0 (0) 0 (0) 4 (4) 21 (20) 81 (76)
7 (6) 34 (31) 41 (38) 21 (19) 6 (6)
39 (33) 81 (53) 29 (19) 2 (1) 2 (1)
50 (28) 105 (58) 23 (13) 2 (1) 0 (0)
0 (0) 10 (29) 16 (46) 9 (26)
0 (0) 36 (38) 35 (37) 24 (25)
0 (0) 1 (1) 46 (30) 105 (69)
10 (5) 35 (19) 65 (36) 72 (40)
75 (70) 31 (29)
50 (45) 62 (55)
46 (30) 107 (70)
55 (30) 127 (70)
55 (51) 15 (14) 1 (1) 1 (1) 10 (9) 25 (23)
61 (54) 20 (18) 0 (0) 1 (1) 8 (7) 22 (20)
56 (37) 41 (27) 4 (3) 1 (1) 19 (13) 30 (20)
76 (42) 54 (30) 3 (2) 3 (2) 16 (9) 30 (16)
1 (1) 24 (22)
4 (4) 22 (19)
5 (3) 25 (16)
3 (2) 29 (16)
29 (27) 17 (16) 31 (29) 5 (5) 0 (0)
28 (25) 23 (20) 31 (27) 4 (4) 1 (1)
36 (23) 41 (27) 39 (25) 8 (5) 0 (0)
37 (20) 39 (21) 67 (37) 8 (4) 0 (0)
*n = 559.
compared with the post–body contouring group. For excess skin, participants in the post–bariatric surgery group reported higher scores (less bothered by excess skin) compared with the pre–body contouring surgery group (p < 0.001). A total of Table 2. Distribution of Weight Loss Method in Body Contouring Patients and Distribution of Type of Bariatric Surgery in All Patients Who Have Undergone Bariatric Surgery Characteristic Distribution of weight loss method in the pre– and post–body contouring groups Bariatric surgery Diet and/or exercise Other Distribution of type of bariatric surgery within all patients who have undergone bariatric surgery Gastric banding Gastric bypass Gastric sleeve
Value (%)
110 patients completed the scar scale, with 87 patients at the 3-month follow-up and 23 patients at the 12-month follow-up. The mean scores for the two time points did not vary significantly (time 1, 73; time 2, 75; p > 0.05 on t test). Figure 2 shows the mean scores for appearance scales (arms, abdomen, back, hips/outer thighs, and inner thighs) comparing the groups of participants who did or did not undergo body contouring surgery to specific parts of their body. The differences in mean scores were significant for four of
339 230 (68) 105 (31) 4 (1)
Table 3. Distribution of Participants versus Number of Assessments
335 6 (2) 301 (90) 28 (8)
1 2 3 4
No. of Assessments per Participant
Participants (n = 493)
% of Total
428 57 7 2
87 12 1 0
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Volume 140, Number 3 • Patient-Reported Outcome and Weight Loss Table 4. Distribution of Post–Body Contouring Surgery Patients Area of Body Contouring Abdomen Arms Back Buttocks Hips and outer thighs Inner thighs Breast Total no. of areas
No. of Procedures
% of Total
169 32 41 24 5 33 39 343
49 9 12 7 2 10 11 100
Table 5. Distribution of Participants versus Reported Areas of Surgery No. of Areas of Body Contouring 1 2 3 4 5 Total
No. of Participants
% of Total
77 64 34 8 1 184
42 35 18 4 1 100
Table 6. Number of Reported Areas in the Subanalysis of Pre–Body Contouring and Post–Body Contouring Surgery According to Different Parts of the Body
appearance scales (exception: buttocks and outer thighs) was significantly (p ≤ 0.017) higher for the group reporting no excess skin compared with the group reporting a lot of excess skin. The group with a lot of excess skin had a significantly (p ≤ 0.022) lower score than the group reporting a moderate amount for two of seven scales (exception: arms, abdomen, buttocks, inner thighs, and hips/outer thighs). There were no significant differences between the groups reporting a little versus a moderate amount of excess skin. The group reporting no excess skin had significantly higher scores for three of seven scales (p ≤ 0.004) compared with the group reporting a little excess skin (exception: back, buttocks, inner thighs, and hips/outer thighs). For the skin scale, we found a significant (p < 0.001) difference between all the skin amount groups, except for the comparison between the group with moderate and the group with a little excess skin. In the back scale, there were only three participants reporting no excess skin; thus, to confirm our results, we recoded the participants reporting no excess skin into missing, which did not change the results for the remaining groups.
Analysis by Body Mass Index Appearance and body mass index were intercorrelated for all seven of the appearance scales (p ≤ 0.001), with higher scores associated with lower body mass index, ranging from −0.16 (inner thigh) to −0.53 (body). For the scales measuring skin and body contouring scars, scores were not significantly correlated with body mass index.
Health-Related Quality-of-Life Scales Analysis by Phase of Journey Figure 3 shows the BODY-Q scores for each of the health-related quality-of-life scales comparing the four phases of the patient journey. For the health-related quality-of-life scales, the mean scores differed significantly (p < 0.001) between the pre– bariatric surgery and post–body contouring surgery groups. In addition, the post–bariatric surgery group reported significantly higher mean scores compared with the pre–bariatric surgery group for five of five scales (p < 0.001). Scores differed significantly for three of five scales (exception: physical and social), comparing the post–bariatric surgery group and the pre–body contouring surgery group, with the pre–body contouring group scoring lower. In addition, pre–body contouring patients reported lower scores than post–body contouring surgery patients (p ≤ 0.001) in four of five scales (exception: physical). [See Appendix, Supplemental Digital Content 2, which shows the physical symptom frequency within phase of weight loss journey, number (percent) of participants, http://links.lww.com/PRS/ C331.] Our findings confirm that the extent of reported symptoms is highest within the pre–bariatric-surgery group.
Analysis by Amount of Excess Skin Patient-reported amounts of excess skin are listed in Table 1. The mean score for five of seven
Analysis by Body Mass Index Health-related quality of life and body mass index intercorrelated for five of five
Area of Body Contouring Abdomen Arms Back Buttocks Hips and outer thighs Inner thighs
Before Surgery (n = 417)
After Surgery (n = 302)
145 61 42 40 43 86
169 32 40 24 5 32
six scales (exception: back and hips/outer thighs), with higher scores reported by the sample of post– body contouring patients (p < 0.001 on t tests). The largest difference in scores was on the inner thigh scale, which was eight times higher in the postsurgical group; and on the abdomen scale, which was five times higher in the postsurgical group.
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Plastic and Reconstructive Surgery • September 2017
Fig. 1. Illustration of changes in patient-reported outcome according to appearance for all participants (regardless of number of body contouring procedures).
Fig. 2. Illustration of changes in patient-reported outcome before and after body contouring surgery for the specific areas of the body.
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Volume 140, Number 3 • Patient-Reported Outcome and Weight Loss
Fig. 3. Mean scores for BODY-Q health-related quality-of-life scales by phase of weight loss journey. HRQOL, health-related quality of life.
health-related quality-of-life scales (p ≤ 0.005). Correlations ranged from −0.12 (sexual) to −0.45 (physical), with lower body mass index associated with higher scores indicative of better healthrelated quality of life.
thus, to confirm our results, we recoded this group into missing, which did not lead to any changes in results for the remaining groups.
Analysis by Excess Skin Amount The group to report having a lot of excess skin reported significantly (p ≤ 0.015) lower scores for health-related quality of life compared with the group without excess skin for four of five scales (exception: physical, which had only three subjects with no skin). The group with a lot of excess skin reported significantly (p ≤ 0.018) higher scores for four of five scales (exception: physical) when compared with the group that reported having a moderate amount of excess skin. The group reporting no excess skin had significantly (p ≤ 0.031) higher scores than the group that reported a little excess skin for two of five scales (exceptions: psychological, sexual, and physical). There were only nine participants who reported no excess skin within the physical function scale;
This cross-sectional analysis provides evidence of important differences in appearance and health-related quality of life for patients at different phases of the weight loss journey. Our study found that higher body mass index and more excess skin were associated with a lower satisfaction with appearance and health-related quality of life. This is in line with findings by Klassen and colleagues, who reported similar results in their study to develop and validate the BODY-Q.19 Although cross-sectional, our findings for bariatric surgery patients using the BODY-Q are similar to longitudinal studies using other patient-reported outcome instruments that show improvement in appearance and health-related quality of life from before bariatric surgery to after bariatric surgery.28–30 In addition, our findings that patient outcomes are
DISCUSSION
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Plastic and Reconstructive Surgery • September 2017 better in patients who undergo body contouring agree with previously published follow-up studies of body contouring surgery.31,32 By phase of journey, the findings for the hips/ outer thighs scale were not as expected (i.e., satisfaction with appearance was higher before compared with after body contouring surgery). However, Figure 2 provides some evidence to suggest that surgery to remove excess skin from that part of the body does in fact change patient perception of appearance of the hips/outer thighs, although it is important to note that we had only five patients who reported previously having undergone surgery on the hip/outer thigh area, which limits generalizability. Furthermore, when patients undergo body contouring for some parts of the body, they may be even more displeased with areas not undergoing surgery. As expected, appraisal of excess skin was lowest in the pre–body contouring group and highest in the post–body contouring group. This finding is in line with the rest of our results and previous studies showing a negative influence of excess skin on health-related quality of life.32–35 An important finding in our study was the tendency for patient satisfaction in the pre– body contouring group to be lower than for the post–bariatric surgery group across most BODYQ appearance and health-related quality-of-life scales. This finding may relate to our previous qualitative publication about expectations, where we found that bariatric surgery patients did not expect the amount of excess skin that they had after weight loss or the impact the skin would have on their appearance and health-related quality of life.35 This finding underlines the importance of patient education to ensure realistic expectations.36 Our findings of a decrease in satisfaction also support a previous qualitative study by Magdaleno et al., as they describe that a patient’s body image perception and psychological state may actually deteriorate following weight loss achieved through bariatric surgery.37 Our study has several limitations. First, our study highlights a challenge that is associated with studying the benefit of body contouring. Although our pre–body contouring sample was “pure” and included only patients who had not undergone any body contouring, our postoperative sample included patients who had undergone at least one or more body contouring procedures (most had undergone abdominoplasty). What this means practically is that many participants in the post–body contouring surgery group were not at the end of their weight loss journey and
therefore could improve even further. Second, our study is cross-sectional and did not measure change over time. Third, the 12-month follow-up clinic for post–body contouring surgery represents a short-term outcome, and with almost half of participants in this group being only 3 months after body contouring surgery, this might influence results negatively, especially in the area of physical well-being, as the recovery process may not be completed. Finally, the analysis comparing the amount of excess skin was subjective and related to the entire body, and an objective measure of excess skin would have strengthened our study.38 An important limitation in the current literature is the lack of studies that follow patients throughout their entire weight loss journey from obesity to the post–body contouring surgery period with a clinically sound, meaningful, well-developed, patient-reported outcome instrument. A strength of our study was that we had the opportunity to measure outcomes using a patient-reported outcome instrument specifically developed for this purpose. Furthermore, our study took place in Denmark, where both bariatric surgery and body contouring are available in the public system for all patients within specific criteria.39 Therefore, our study sample represents a cross-sectional sample of patients who qualify for treatment at the four departments where recruitment took place.
CONCLUSIONS Our findings underline the importance of body contouring surgery for the completion of the weight loss journey following massive weight loss. In Denmark, body contouring following massive weight loss, often achieved through bariatric surgery, is funded by the public health care system. In many countries around the world, body contouring and the removal of excess skin is considered aesthetic by nature.9,40 Our study provides evidence to suggest that body contouring plays an important role in the patient journey and that patients need access to treatments to prevent the negative influence of excess skin and instead improve satisfaction with appearance and healthrelated quality of life. Lotte Poulsen, M.D. Department of Plastic Surgery Odense University Hospital Sdr. Boulevard 29 5000 Odense, Denmark [email protected]
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Volume 140, Number 3 • Patient-Reported Outcome and Weight Loss ACKNOWLEDGMENT
The study was supported by a fund received from the region of southern Denmark and the Internationalization Fund at Odense University Hospital. REFERENCES 1. World Health Organization. Obesity and overweight. Available at: http://www.who.int/mediacentre/factsheets/ fs311/en/. Accessed December 12, 2016. 2. Global BMI Mortality Collaboration; de Angelantonio E, Bhupathiraju ShN, Wormser D, et al. Body-mass index and all-cause mortality: Individual- participant-data meta-analysis of 239 prospective studies in four continents. Lancet 2016;388:776–786. 3. Colquitt JL, Pickett K, Loveman E, et al. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;8:CD003641. 4. Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric surgery worldwide 2013. Obes Surg. 2015;25:1822–1832. 5. American Society for Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers, 2011–2015. Available at: https:// asmbs.org/resources/estimate-of-bariatric-surgery-numbers. Accessed December 12, 2016. 6. Modarressi A, Balagué N, Huber O, Chilcott M, PittetCuénod B. Plastic surgery after gastric bypass improves longterm quality of life. Obes Surg. 2013;23:24–30. 7. Karlsson J, Taft C, Rydén A, Sjöström L, Sullivan M. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: The SOS intervention study. Int J Obes (Lond.) 2007;31:1248–1261. 8. Karlsson J, Sjöström L, Sullivan M. Swedish obese subjects (SOS): An intervention study of obesity. Two-year follow-up of health-related quality of life (HRQL) and eating behavior after gastric surgery for severe obesity. Int J Obes Relat Metab Disord. 1998;22:113–126. 9. Ellison JM, Steffen KJ, Sarwer DB. Body contouring after bariatric surgery. Eur Eat Disord Rev. 2015;23:479–487. 10. Poulsen L, Rose M, Klassen A, et al. Danish translation and linguistic validation of the BODY-Q: A description of the process. Eur J Plast Surg. 2017;40:29–38. 11. Poulsen L, Klassen A, Rose M, et al. Psychometric validation of the BODY-Q in Danish patients undergoing weight loss and body contouring surgery. Plast Reconstr Surg. (in press). 12. Tayyem R, Ali A, Atkinson J, Martin CR. Analysis of healthrelated quality-of-life instruments measuring the impact of bariatric surgery: Systematic review of the instruments used and their content validity. Patient 2011;4:73–87. 13. Reavey PL, Klassen AF, Cano SJ, et al. Measuring quality of life and patient satisfaction after body contouring: A systematic review of patient-reported outcome measures. Aesthet Surg J. 2011;31:807–813. 14. Jabir S. Assessing improvement in quality of life and patient satisfaction following body contouring surgery in patients with massive weight loss: A critical review of outcome measures employed. Plast Surg Int. 2013;2013:515737. 15. Morley D, Jenkinson C, Fitzpatrick R. A Structured Review of Patient-Reported Outcome Measures Used in Cosmetic Surgical Procedures. Oxford: Health Services Research Unit Department of Public Health University of Oxford; 2013. 16. Danilla S, Cuevas P, Aedo S, et al. Introducing the Body-QoL: A new patient-reported outcome instrument for measuring body satisfaction-related quality of life in aesthetic and post-bariatric body contouring patients. Aesthetic Plast Surg. 2016;40:19–29.
17. Gilmartin J, Bath-Hextall F, Maclean J, Stanton W, Soldin M. Quality of life among adults following bariatric and body contouring surgery: A systematic review. JBI Database System Rev Implement Rep. 2016;14:240–270. 18. Klassen AF, Cano SJ, Scott A, Tsangaris E, Pusic AL. Assessing outcomes in body contouring. Clin Plast Surg. 2014;41:645–654. 19. Klassen A, Cano SJ, Alderman A, et al. The BODY-Q: A patientreported outcome instrument for weight loss and body contouring treatments. Plast Reconstr Surg Glob Open 2016;4:e679. 20. Lasch KE, Marquis P, Vigneux M, et al. PRO development: Rigorous qualitative research as the crucial foundation. Qual Life Res. 2010;19:1087–1096. 21. Patrick DL, Burke LB, Gwaltney CJ, et al. Content validity: Establishing and reporting the evidence in newly developed patient-reported outcomes (PRO) instruments for medical product evaluation: ISPOR PRO good research practices task force report: Part 1—Eliciting concepts for a new PRO instrument. Value Health 2011;14:967–977. 22. Scientific Advisory Committee of the Medical Outcomes Trust. Assessing health status and quality of life instruments: Attributes and review criteria. Qual Life Res. 2002; 11:193–205. 23. COSMIN. COSMIN checklist. Available at: http://www.cosmin. nl/the_cosmin_checklist.html. Accessed December 12, 2016. 24. Mokkink LB, Terwee CB, Patrick DL, et al. The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. J Clin Epidemiol. 2010;63:737–745. 25. Mokkink LB, Terwee CB, Patrick DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: An international Delphi study. Qual Life Res. 2010;19:539–549. 26. Rasch Measurement Forum. Sample size and item calibration [or person measure] stability. Available at: http://www. rasch.org/rmt/rmt74m.htm. Accessed December 12, 2016. 27. OPEN Odense Patient data Explorative Network Department of Clinical Research University of Southern Denmark. OPEN (Web site). Available at: http://www.sdu.dk/en/om_sdu/ institutter_centre/klinisk_institut/forskning/forskningsenheder/open. Accessed December 12, 2016. 28. Teufel M, Rieber N, Meile T, et al. Body image after sleeve gastrectomy: Reduced dissatisfaction and increased dynamics. Obes Surg. 2012;22:1232–1237. 29. Burgmer R, Legenbauer T, Müller A, de Zwaan M, Fischer C, Herpertz S. Psychological outcome 4 years after restrictive bariatric surgery. Obes Surg. 2014;24:1670–1678. 30. de Zwaan M, Georgiadou E, Stroh CE, et al. Body image and quality of life in patients with and without body contouring surgery following bariatric surgery: A comparison of pre- and post-surgery groups. Front Psychol. 2014;5:1310. 31. Tremp M, Delko T, Kraljević M, et al. Outcome in bodycontouring surgery after massive weight loss: A prospective matched single-blind study. J Plast Reconstr Aesthet Surg. 2015;68:1410–1416. 32. Kitzinger HB, Abayev S, Pittermann A, et al. After massive weight loss: Patients’ expectations of body contouring surgery. Obes Surg. 2012;22:544–548. 33. Kinzl JF, Traweger C, Trefalt E, Biebl W. Psychosocial consequences of weight loss following gastric banding for morbid obesity. Obes Surg. 2003;13:105–110. 34. Klassen AF, Cano SJ, Scott A, Johnson J, Pusic AL. Satisfaction and quality-of-life issues in body contouring surgery patients: A qualitative study. Obes Surg. 2012;22:1527–1534.
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Plastic and Reconstructive Surgery • September 2017 35. Poulsen L, Klassen A, Jhanwar S, et al. Patient expectations of bariatric and body contouring surgery. Plast Reconstr Surg Glob Open 2016;4:e694. 36. Waljee J, McGlinn EP, Sears ED, Chung KC. Patient expectations and patient-reported outcomes in surgery: A systematic review. Surgery 2014;155:799–808. 37. Magdaleno R Jr, Chaim EA, Pareja JC, Turato ER. The psychology of bariatric patient: What replaces obesity? A qualitative research with Brazilian women. Obes Surg. 2011;21:336–339.
38. Biörserud C, Fagevik Olsén M, Elander A, Wiklund M. Objective measurements of excess skin in post bariatric patients: Interrater reliability. J Plast Surg Hand Surg. 2016;50:68–73. 39. Danish National Guidelines for Body Contouring Surgery after Massive Weight Loss. Copenhagen: Sundhedsstyrelsen, Sygehuse og Beredskab; 2013. 40. Tan A, Caine P, Barnes D. Re: Outcome in body-contouring surgery after massive weight loss: A prospective matched singleblind study. J Plast Reconstr Aesthet Surg. 2015;68:1767–1768.
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Patient-Reported Outcomes in Weight Loss and Body Contouring Surgery: A Cross-Sectional Analysis Using the BODY-Q Lotte Poulsen, M.D. Anne Klassen, D.Phil., Ph.D. Michael Rose, M.D. Kirsten K. Roessler, D.Phil., Ph.D. Claus Bogh Juhl, M.D., Ph.D. René Klinkby Støving, M.D., Ph.D. Jens Ahm Sørensen, M.D., Ph.D. Odense and Esbjerg, Denmark; and Hamilton, Ontario, Canada
Background: Health-related quality of life and satisfaction with appearance are important outcomes in bariatric and body contouring surgery. To investigate these outcomes, scientifically sound and clinically meaningful patient-reported outcome instruments are needed. The authors measured health-related quality of life and appearance in a cohort of Danish patients at different phases in the weight loss journey: before bariatric surgery, after bariatric surgery, before body contouring surgery, and after body contouring surgery. Methods: From June of 2015 to June of 2016, a cross-sectional sample of 493 bariatric and body contouring patients were recruited from four different hospital departments. Patients were asked to fill out the BODY-Q, a new patientreported outcomes instrument designed specifically to measure health-related quality of life and appearance over the entire patient journey, from obesity to the post–body contouring surgery period. Data were collected using REDCap, and analyzed using SPSS software. Results: For all appearance and health-related quality-of-life scales, the mean score was significantly lower in the pre–bariatric surgery group compared with the post–body contouring group. Furthermore, the correlation between body mass index and mean scores was significant for all appearance and healthrelated quality-of-life scales, with higher scores associated with lower body mass index. The mean score for the group reporting no excess skin compared with the group reporting a lot of excess skin was significantly higher for five of seven appearance scales and four of five health-related quality-of-life scales. Conclusion: This study provides evidence to suggest that body contouring plays an important role in the weight loss patient’s journey and that patients need access to treatments. (Plast. Reconstr. Surg. 140: 491, 2017.)
O
besity has more than doubled since 1980,1 and a meta-analysis on body mass index and mortality showed that mortality in people with a body mass index over 25 kg/m2 increased approximately log-linearly.2 Bariatric surgery has been shown to be the most effective treatment of moderate to severe obesity, which From the Department of Plastic Surgery, the Odense Patient Data Explorative Network, the Center for Eating Disorders and Department of Endocrinology, and the Department of Plastic Surgery, Odense University Hospital; the Department of Pediatrics, McMaster University; the Departments of Plastic Surgery and Endocrinology, Hospital of Southwest Jutland; and the Institute of Psychology and the Psychiatric Services in Southern Denmark, University of Southern Denmark. Received for publication December 23, 2016; accepted March 21, 2017. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003605
has led to an increasing number of bariatric procedures performed worldwide.3–5 Health-related quality of life is important to patients seeking bariatric surgery,6 and weight loss following bariatric surgery is associated with improvement in health-related quality of life.7,8 However, massive Disclosure: The authors have no financial interest to declare in relation to the content of this article.
Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www. PRSJournal.com).
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Plastic and Reconstructive Surgery • September 2017 weight loss often leads to excessive skin, which has the potential to have a negative influence on health-related quality of life. Therefore, body contouring surgery is often needed to restore body image and further improve health-related quality of life.9 To measure outcomes such as health-related quality of life and satisfaction with appearance, patient-reported outcome instruments are needed. As described elsewhere,10,11 there is a need for a well-developed patient-reported outcome instrument that can be used across the weight loss journey for bariatric and body contouring patients.12–16 In a recent review, Gilmartin et al. suggest that the newly published BODY-Q could be a candidate tool.17 The BODY-Q is a new patient-reported outcome instrument designed specifically to measure patient-reported outcome over the entire patient journey, from obesity to the post–body contouring surgery period.18,19 The BODY-Q was developed following internationally recommended guidelines for patientreported outcome instrument development.20–25 A strength of the BODY-Q is the use of Rasch measurement theory, which provides interval level measurement scales.21,26 The BODY-Q measures three overall domains—appearance, health-related quality of life, and the patients’ experience of health care—in terms of 18 independently functioning scales. In addition, the BODY-Q includes an obesity-specific physical symptom checklist. In Denmark, the BODY-Q was translated into Danish in a linguistic validation study.10 In addition, a psychometric validation study was performed with the findings described in detail elsewhere.10,11 Briefly, the Danish version of the BODY-Q was found to be acceptable to Danish patients (e.g., high response rate and low amount of missing data) and to evidence reliability (Cronbach alphas > 0.90 and person separation indices > 0.80 for the appearance and health-related quality-of-life scales).11 The objective of this study was to measure health-related quality of life and appearance using BODY-Q scales in a cohort of Danish patients at different phases in the weight loss journey. Our specific aim was to explore relationships between BODY-Q scale scores and the following variables: (1) phase of weight loss journey (i.e., before bariatric surgery, after bariatric surgery, before body contouring surgery, and after body contouring surgery); (2) body mass index; and (3) amount of self-reported excess skin.
PATIENTS AND METHODS Before commencement, the study was reported to the Danish Data Protection Agency and the Regional Scientific Ethical Committee of Southern Denmark. As our study consists of a questionnaire survey, the ethical committee did not find reason for an approval. Data Collection and Sample The study was carried out as an online questionnaire survey using the Danish version of the BODY-Q.10,11 Patients from the region of southern Denmark were recruited from four different departments: the Department of Endocrinology, Hospital of Southwest Jutland; the Department of Endocrinology, Odense University Hospital; the Department of Plastic Surgery, Hospital of Southwest Jutland; and the Department of Plastic Surgery, Odense University Hospital. All patients seen at the following time points between June of 2015 and June of 2016 were invited to complete the BODY-Q: (1) first visit at the weight loss clinic; (2) before the bariatric surgery appointment; (3) 4 to 5 months after bariatric surgery; (4) 12 months after bariatric surgery; (5) 24 months after bariatric surgery, (6) before body contouring surgery; (7) 3 months after body contouring surgery; and (8) 12 months after body contouring surgery. Data were collected using a REDCap (i.e., Research Electronic Data Capture) database designed for this study (http://project-redcap. org). Access to REDCap was granted through the Odense Patient Data Explorative Network.27 Patients received a letter together with their appointment information and information about the study with a link to access the electronic REDCap link to complete the BODY-Q. At the Hospital of Southwest Jutland, patients received mobile text reminders before their scheduled appointment. The text messages included a reminder to fill out the BODY-Q before their outpatient visit. Through the last 3 months of the study, we aimed to invite patients who failed to complete the questionnaire in advance of their appointment to do so on arrival to the clinic using a tablet. Outcome and Demographic and Clinical Variables The online survey included the BODY-Q appearance scales (body, abdomen, upper arms, buttocks, back, inner thighs, hips/outer thighs, skin, and body contouring scars) and health-related quality-of-life scales (body image and physical, psychological, sexual, and social function), plus relevant demographic
492 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 140, Number 3 • Patient-Reported Outcome and Weight Loss and clinical questions. The sample was categorized into four subgroups as follows: (1) pre–bariatric surgery (i.e., participants recruited at their first visit to the weight loss clinic or at the pre–bariatric surgery appointment); (2) post-bariatric surgery (i.e., participants recruited at the 4- to 5-month or 12-month follow-up appointments); (3) pre–body contouring (i.e., participants recruited from any of the body contouring clinics who reported that they had never previously undergone any body contouring surgery, but needed surgery to remove excess skin from any part of their body); and (4) post–body contouring (i.e., patients recruited from any of the body contouring clinics who had previously undergone at least one body contouring procedure to remove excess skin). For body contouring participants, we also computed a set of dichotomous variables to compare BODY-Q scores for participants who reported being either preoperative or postoperative for body contouring to remove excess skin from the following areas of their body: abdomen, arms, back, buttocks, inner thighs, and hips/outer thighs. Finally, to explore relationships between amount of excess skin and BODY-Q scores, patients were asked to self-report the amount of excess skin they have on their body as follows: none, a little, a moderate amount, or a lot. Statistical Analysis BODY-Q scales can be scored if at least half of the items are completed (the mean is imputed when there are missing data). For each scale, the raw score was computed and converted to a Rasch transformed score (range, 0 to 100). Low BODY-Q scores indicate low satisfaction with outcome, whereas higher scores indicate a better outcome. To test equality of the mean, we computed either a parametric (t test or one-way analysis of variance with Tukey post hoc test) or nonparametric (Mann-Whitney U tests or Wilcoxon) test, depending on the distribution of the data, after examining homogeneity of variance and normality assumptions. A value of p < 0.05 was considered statistically significant, and 95 percent confidence intervals were computed. Data analysis was performed using IBM SPSS Version 22 (IBM Corp., Armonk, N.Y.).
RESULTS Sample Characteristics A total of 493 patients completed the BODY-Q. Sample characteristics are shown in Table 1. For the bariatric group, the response rate was 83 percent; for the body contouring group, the response rate
was 72 percent. The overall response rate was 76 percent. Details on the distribution of weight loss method and type of bariatric surgery are provided in Table 2. As patients were recruited over a 1-year period, some patients (13 percent) were asked to complete the BODY-Q more than once (Table 3). The 493 patients provided 559 assessments, 19 percent by pre–bariatric surgery patients, 20 percent by post–bariatric surgery patients, 28 percent by pre–body contouring surgery patients, and 33 percent by post–body contouring surgery patients. For the 339 patients in the body contouring group, 155 were preoperative and had never had any surgery. The remaining 184 patients in this group were post–body contouring surgery patients for at least one of the seven areas of the body, of which 107 respondents had undergone surgery on more than one part of the body. Within the post–body contouring group, 88 patients reported to be at the 3-month follow-up at the time of assessment. The most common procedure was correction of the abdomen, which 92 percent of the post–body contouring group had undergone. Details on the number of patients to report having undergone surgery for the seven different areas of the body, and the cumulative number of procedures reported, are listed in Table 4. Table 5 shows the number of reported areas in the subanalysis of before and after body contouring surgery according to different parts of the body. For an overview of the mean scores and analysis of variance findings by phase of weight loss journey for each BODY-Q scale, see Appendix 1. (See Appendix, Supplemental Digital Content 1, which shows the mean scores and associated statistics for BODY-Q scales by phase of weight loss journey, http://links.lww.com/PRS/C330.) Appearance Scales Analysis by Phase of Journey Figure 1 illustrates the BODY-Q appearance scales by phase in the weight loss journey. For the seven appearance scales, the mean score was significantly lower in the pre–bariatric surgery group compared with the post–body contouring group (p < 0.001). For six of seven areas (exception: arms) scores were significantly lower in the pre–bariatric surgery group compared with the post–bariatric surgery group (p ≤ 0.011), and the post–bariatric surgery and pre–body contouring groups differed significantly (p < 0.001) on two of seven scales (body and abdomen), with the pre–body contouring group reporting lower scores. Pre–body contouring patients reported significantly lower scores (p ≤ 0.027) on four of seven scales (body, abdomen, back, and buttocks)
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Plastic and Reconstructive Surgery • September 2017 Table 1. Sample Characteristics, Divided by Phase of Weight Loss Journey* Characteristic No. Age, yr Mean Range Sex Female Male BMI Normal (18.5–24.9 kg/m2) Overweight (25–29.9 kg/m2) Class I (35–39.9 kg/m2) Class II (35–39.9 kg/m2) Class III (≥40 kg/m2) Self-reported amount of excess skin None A little Moderate A lot Comorbidity Yes No Marital status Married Living together Widow Separated Divorced Single, never married Education None Primary school Youth, vocational, or secondary education Short higher education Medium higher education Long higher education Ph.D. or master’s
No.
559 548
464
553 552
557
Before Bariatric Surgery (%)
After Bariatric Surgery (%)
Before Body Contouring (%)
After Body Contouring (%)
107
113
115
184
43 21–63
42 23–65
42 17–66
44 23–75
72 (67) 35 (33)
82 (73) 31 (27)
123 (79) 32 (21)
160 (87) 24 (13)
0 (0) 0 (0) 4 (4) 21 (20) 81 (76)
7 (6) 34 (31) 41 (38) 21 (19) 6 (6)
39 (33) 81 (53) 29 (19) 2 (1) 2 (1)
50 (28) 105 (58) 23 (13) 2 (1) 0 (0)
0 (0) 10 (29) 16 (46) 9 (26)
0 (0) 36 (38) 35 (37) 24 (25)
0 (0) 1 (1) 46 (30) 105 (69)
10 (5) 35 (19) 65 (36) 72 (40)
75 (70) 31 (29)
50 (45) 62 (55)
46 (30) 107 (70)
55 (30) 127 (70)
55 (51) 15 (14) 1 (1) 1 (1) 10 (9) 25 (23)
61 (54) 20 (18) 0 (0) 1 (1) 8 (7) 22 (20)
56 (37) 41 (27) 4 (3) 1 (1) 19 (13) 30 (20)
76 (42) 54 (30) 3 (2) 3 (2) 16 (9) 30 (16)
1 (1) 24 (22)
4 (4) 22 (19)
5 (3) 25 (16)
3 (2) 29 (16)
29 (27) 17 (16) 31 (29) 5 (5) 0 (0)
28 (25) 23 (20) 31 (27) 4 (4) 1 (1)
36 (23) 41 (27) 39 (25) 8 (5) 0 (0)
37 (20) 39 (21) 67 (37) 8 (4) 0 (0)
*n = 559.
compared with the post–body contouring group. For excess skin, participants in the post–bariatric surgery group reported higher scores (less bothered by excess skin) compared with the pre–body contouring surgery group (p < 0.001). A total of Table 2. Distribution of Weight Loss Method in Body Contouring Patients and Distribution of Type of Bariatric Surgery in All Patients Who Have Undergone Bariatric Surgery Characteristic Distribution of weight loss method in the pre– and post–body contouring groups Bariatric surgery Diet and/or exercise Other Distribution of type of bariatric surgery within all patients who have undergone bariatric surgery Gastric banding Gastric bypass Gastric sleeve
Value (%)
110 patients completed the scar scale, with 87 patients at the 3-month follow-up and 23 patients at the 12-month follow-up. The mean scores for the two time points did not vary significantly (time 1, 73; time 2, 75; p > 0.05 on t test). Figure 2 shows the mean scores for appearance scales (arms, abdomen, back, hips/outer thighs, and inner thighs) comparing the groups of participants who did or did not undergo body contouring surgery to specific parts of their body. The differences in mean scores were significant for four of
339 230 (68) 105 (31) 4 (1)
Table 3. Distribution of Participants versus Number of Assessments
335 6 (2) 301 (90) 28 (8)
1 2 3 4
No. of Assessments per Participant
Participants (n = 493)
% of Total
428 57 7 2
87 12 1 0
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Volume 140, Number 3 • Patient-Reported Outcome and Weight Loss Table 4. Distribution of Post–Body Contouring Surgery Patients Area of Body Contouring Abdomen Arms Back Buttocks Hips and outer thighs Inner thighs Breast Total no. of areas
No. of Procedures
% of Total
169 32 41 24 5 33 39 343
49 9 12 7 2 10 11 100
Table 5. Distribution of Participants versus Reported Areas of Surgery No. of Areas of Body Contouring 1 2 3 4 5 Total
No. of Participants
% of Total
77 64 34 8 1 184
42 35 18 4 1 100
Table 6. Number of Reported Areas in the Subanalysis of Pre–Body Contouring and Post–Body Contouring Surgery According to Different Parts of the Body
appearance scales (exception: buttocks and outer thighs) was significantly (p ≤ 0.017) higher for the group reporting no excess skin compared with the group reporting a lot of excess skin. The group with a lot of excess skin had a significantly (p ≤ 0.022) lower score than the group reporting a moderate amount for two of seven scales (exception: arms, abdomen, buttocks, inner thighs, and hips/outer thighs). There were no significant differences between the groups reporting a little versus a moderate amount of excess skin. The group reporting no excess skin had significantly higher scores for three of seven scales (p ≤ 0.004) compared with the group reporting a little excess skin (exception: back, buttocks, inner thighs, and hips/outer thighs). For the skin scale, we found a significant (p < 0.001) difference between all the skin amount groups, except for the comparison between the group with moderate and the group with a little excess skin. In the back scale, there were only three participants reporting no excess skin; thus, to confirm our results, we recoded the participants reporting no excess skin into missing, which did not change the results for the remaining groups.
Analysis by Body Mass Index Appearance and body mass index were intercorrelated for all seven of the appearance scales (p ≤ 0.001), with higher scores associated with lower body mass index, ranging from −0.16 (inner thigh) to −0.53 (body). For the scales measuring skin and body contouring scars, scores were not significantly correlated with body mass index.
Health-Related Quality-of-Life Scales Analysis by Phase of Journey Figure 3 shows the BODY-Q scores for each of the health-related quality-of-life scales comparing the four phases of the patient journey. For the health-related quality-of-life scales, the mean scores differed significantly (p < 0.001) between the pre– bariatric surgery and post–body contouring surgery groups. In addition, the post–bariatric surgery group reported significantly higher mean scores compared with the pre–bariatric surgery group for five of five scales (p < 0.001). Scores differed significantly for three of five scales (exception: physical and social), comparing the post–bariatric surgery group and the pre–body contouring surgery group, with the pre–body contouring group scoring lower. In addition, pre–body contouring patients reported lower scores than post–body contouring surgery patients (p ≤ 0.001) in four of five scales (exception: physical). [See Appendix, Supplemental Digital Content 2, which shows the physical symptom frequency within phase of weight loss journey, number (percent) of participants, http://links.lww.com/PRS/ C331.] Our findings confirm that the extent of reported symptoms is highest within the pre–bariatric-surgery group.
Analysis by Amount of Excess Skin Patient-reported amounts of excess skin are listed in Table 1. The mean score for five of seven
Analysis by Body Mass Index Health-related quality of life and body mass index intercorrelated for five of five
Area of Body Contouring Abdomen Arms Back Buttocks Hips and outer thighs Inner thighs
Before Surgery (n = 417)
After Surgery (n = 302)
145 61 42 40 43 86
169 32 40 24 5 32
six scales (exception: back and hips/outer thighs), with higher scores reported by the sample of post– body contouring patients (p < 0.001 on t tests). The largest difference in scores was on the inner thigh scale, which was eight times higher in the postsurgical group; and on the abdomen scale, which was five times higher in the postsurgical group.
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Plastic and Reconstructive Surgery • September 2017
Fig. 1. Illustration of changes in patient-reported outcome according to appearance for all participants (regardless of number of body contouring procedures).
Fig. 2. Illustration of changes in patient-reported outcome before and after body contouring surgery for the specific areas of the body.
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Volume 140, Number 3 • Patient-Reported Outcome and Weight Loss
Fig. 3. Mean scores for BODY-Q health-related quality-of-life scales by phase of weight loss journey. HRQOL, health-related quality of life.
health-related quality-of-life scales (p ≤ 0.005). Correlations ranged from −0.12 (sexual) to −0.45 (physical), with lower body mass index associated with higher scores indicative of better healthrelated quality of life.
thus, to confirm our results, we recoded this group into missing, which did not lead to any changes in results for the remaining groups.
Analysis by Excess Skin Amount The group to report having a lot of excess skin reported significantly (p ≤ 0.015) lower scores for health-related quality of life compared with the group without excess skin for four of five scales (exception: physical, which had only three subjects with no skin). The group with a lot of excess skin reported significantly (p ≤ 0.018) higher scores for four of five scales (exception: physical) when compared with the group that reported having a moderate amount of excess skin. The group reporting no excess skin had significantly (p ≤ 0.031) higher scores than the group that reported a little excess skin for two of five scales (exceptions: psychological, sexual, and physical). There were only nine participants who reported no excess skin within the physical function scale;
This cross-sectional analysis provides evidence of important differences in appearance and health-related quality of life for patients at different phases of the weight loss journey. Our study found that higher body mass index and more excess skin were associated with a lower satisfaction with appearance and health-related quality of life. This is in line with findings by Klassen and colleagues, who reported similar results in their study to develop and validate the BODY-Q.19 Although cross-sectional, our findings for bariatric surgery patients using the BODY-Q are similar to longitudinal studies using other patient-reported outcome instruments that show improvement in appearance and health-related quality of life from before bariatric surgery to after bariatric surgery.28–30 In addition, our findings that patient outcomes are
DISCUSSION
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Plastic and Reconstructive Surgery • September 2017 better in patients who undergo body contouring agree with previously published follow-up studies of body contouring surgery.31,32 By phase of journey, the findings for the hips/ outer thighs scale were not as expected (i.e., satisfaction with appearance was higher before compared with after body contouring surgery). However, Figure 2 provides some evidence to suggest that surgery to remove excess skin from that part of the body does in fact change patient perception of appearance of the hips/outer thighs, although it is important to note that we had only five patients who reported previously having undergone surgery on the hip/outer thigh area, which limits generalizability. Furthermore, when patients undergo body contouring for some parts of the body, they may be even more displeased with areas not undergoing surgery. As expected, appraisal of excess skin was lowest in the pre–body contouring group and highest in the post–body contouring group. This finding is in line with the rest of our results and previous studies showing a negative influence of excess skin on health-related quality of life.32–35 An important finding in our study was the tendency for patient satisfaction in the pre– body contouring group to be lower than for the post–bariatric surgery group across most BODYQ appearance and health-related quality-of-life scales. This finding may relate to our previous qualitative publication about expectations, where we found that bariatric surgery patients did not expect the amount of excess skin that they had after weight loss or the impact the skin would have on their appearance and health-related quality of life.35 This finding underlines the importance of patient education to ensure realistic expectations.36 Our findings of a decrease in satisfaction also support a previous qualitative study by Magdaleno et al., as they describe that a patient’s body image perception and psychological state may actually deteriorate following weight loss achieved through bariatric surgery.37 Our study has several limitations. First, our study highlights a challenge that is associated with studying the benefit of body contouring. Although our pre–body contouring sample was “pure” and included only patients who had not undergone any body contouring, our postoperative sample included patients who had undergone at least one or more body contouring procedures (most had undergone abdominoplasty). What this means practically is that many participants in the post–body contouring surgery group were not at the end of their weight loss journey and
therefore could improve even further. Second, our study is cross-sectional and did not measure change over time. Third, the 12-month follow-up clinic for post–body contouring surgery represents a short-term outcome, and with almost half of participants in this group being only 3 months after body contouring surgery, this might influence results negatively, especially in the area of physical well-being, as the recovery process may not be completed. Finally, the analysis comparing the amount of excess skin was subjective and related to the entire body, and an objective measure of excess skin would have strengthened our study.38 An important limitation in the current literature is the lack of studies that follow patients throughout their entire weight loss journey from obesity to the post–body contouring surgery period with a clinically sound, meaningful, well-developed, patient-reported outcome instrument. A strength of our study was that we had the opportunity to measure outcomes using a patient-reported outcome instrument specifically developed for this purpose. Furthermore, our study took place in Denmark, where both bariatric surgery and body contouring are available in the public system for all patients within specific criteria.39 Therefore, our study sample represents a cross-sectional sample of patients who qualify for treatment at the four departments where recruitment took place.
CONCLUSIONS Our findings underline the importance of body contouring surgery for the completion of the weight loss journey following massive weight loss. In Denmark, body contouring following massive weight loss, often achieved through bariatric surgery, is funded by the public health care system. In many countries around the world, body contouring and the removal of excess skin is considered aesthetic by nature.9,40 Our study provides evidence to suggest that body contouring plays an important role in the patient journey and that patients need access to treatments to prevent the negative influence of excess skin and instead improve satisfaction with appearance and healthrelated quality of life. Lotte Poulsen, M.D. Department of Plastic Surgery Odense University Hospital Sdr. Boulevard 29 5000 Odense, Denmark [email protected]
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Volume 140, Number 3 • Patient-Reported Outcome and Weight Loss ACKNOWLEDGMENT
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